Osteochondrosis of the lumbosacral spine: diagnosis and treatment.

Osteochondrosis of the lumbar region is a disease that deforms and destroys the cartilaginous tissue of the intervertebral discs in the lower back.Without cartilage layer, the distance between the vertebrae is significantly reduced.And with the slightest sharp turns, they can shift.The main danger of the disease is the possibility of the formation of intervertebral hernia.

Can't you lean to raise an object that has fallen to the floor?Do you suffer acute pain in the lumbar spine and often go, wrapping the waist into a warm scarf?Do not ignore the condition that bothers you.

Osteochondrosis of the lumbar region can drag on by its duration for a long time.There is no need to experience the body for strength.Love your body.And it will reciprocate.

The lumbar region accounts for most of the load from all body weight compared to the chest and cervical departments.Therefore, this subspecies of osteochondrosis is the most common.

What are the stages of development of osteochondrosis?

• 1st stage.Preclined.The height of the disc is reduced.In the fibrous ring (the outer layer of the intervertebral disc from the cartilaginous fibers) a crack is formed.The lumbar muscles begin to get tired quickly.You feel certain discomfort in the back.
• Stage 2.Violations of metabolic processes in the jacket of the core (central part of the intervertebral disc, which consists of a jacket of cartilage): its cells are dead or completely destroyed.The collagen structure (the protein structure is based on the connective tissue) of the fibrous ring is also disturbed.Local pains, a person cannot cope with the physical activity that he previously considered quite feasible.
• Stage 3.Complete destruction of the fibrous ring.Adjacent vertebrae cease to be stable.Any uncomfortable pose causes pain.Due to the experience of nerve roots that move away from the spinal cord, limbs can become less sensitive and mobile.
• 4th stage.The fabrics of the intervertebral disk become cicatricious.The vertebra may turn out to be in the shell shell.The clinical description here depends on individual physiology.

Lumbar pain (lumbago) and pain that gives to the leg during the sciatic nerve (Ishias) is one of the most common complaints that patients seek medical help.Due to the fact that these symptoms are quite common in the general population, and their steady growth is also noted, the diagnosis and treatment of such patients will remain one of the main areas of activity of neurosurgical hospitals.Despite the widespread of this pathology, the surgical removal of the hernia of the intervertebral disc (MPD) is required only in 10% of patients with the clinical picture of lumbar -algia.In the remaining part of patients, the best effect has a conservative treatment, including drug therapy, physiotherapy exercises, the use of physiotherapeutic methods of treatment, as well as a return to previous everyday physical activity.

Stages of the disease

Degenerative-dystrophic processes most often begin with a deterioration in the shock-absorbing function of the intervertebral disc.

1. Deterioration of blood supply to the intervertebral disc.In adults, the food of the intervertebral discs is carried out by diffusion: blood is delivered only to the vertebrae, and already through them it “seeps” to the discs.In the best way, the disk is powered during dynamic loads (for example, walking), since the principle of the pump (outflow of the processed fluid when compressed, the flow of nutrients and oxygen when removing the load).Thus, the nutrition of intervertebral discs is difficult especially in the conditions of a sedentary lifestyle (hypodynamia).
2. Changes in the pulpic disk core.With a deterioration in blood supply, the supply of water, sugars and amino acids to the pulpoose nucleus is disturbed.Because of this, the production of carbohydrates connecting water suffers.The nucleus is dehydrated, its structure made of gel -like turns into fibrous, the ability to spring and extinguish shots worsens.This increases the load on the fibrous ring and vertebrae, they are more likely to be blocked and injured.
3. Changes in the fibrous ring of the intervertebral disc.Due to the flattening of the pulpoose nucleus, the increased load lies on the fibrous disc ring.In conditions of poor blood supply, the fibrous ring loses its strength.The instability of the spine occurs, which can lead to the formation of an intervertebral hernia, a displacement of the vertebrae and damage to the spinal cord or nerve roots.
4. Disk protrusion.The formation of intervertebral hernia.As the fibers of the fibrous ring weaken, the pulpic nucleus begins to stick out, for example, towards the intervertebral canal (disk protrusion).Such a staggering can further lead to a rupture of a fibrous ring and the formation of a hernia.Read more about the process of formation of intervertebral hernia in a separate article - “Effective treatment of intervertebral hernia at home”.
5. Spondylosis is the destruction of the intervertebral joints (spondylartrosis), the growth of osteofites and the ossification of ligaments.In parallel with the formation of intervertebral hernia in osteochondrosis, damage to the intervertebral joints, destructive changes in the vertebra (cartilage) and ligaments are observed.

As osteochondrosis and the development of complications progress, you have to resort to medication more and more often, increase dosages.This leads to high financial costs, as well as further deterioration in health due to side effects of drugs.

Drug therapy, as a rule, is supplemented by immobilization of one or friend of the spine using orthopedic corsets of varying degrees of stiffness.

Surgical treatment is justified only in cases where the level of compression of the spinal rook, determined by the clinically, corresponds to the examination confirming the rupture of the fibrous ring with the “loss” of the hernia of the MPD into the lumen of the vertebral canal [3–6].The results of surgical treatment in patients with small protrusions of the disk, as a rule, are disappointed with doctors and the patient himself.The method to establish an accurate diagnosis is magnetic resonance imaging (MRI).Approximately 10% of people of a common population is impossible to conduct routine MRI because of claustrophobia (fear of closed spaces).In this category of persons, it is possible to use the so -called "open" MRI, however, with the corresponding loss of quality of images obtained.Patients who have previously suffered surgical treatment are required to carry out an MRI with contrasting reinforcement to delimit the postoperative scar -decay changes from the true hernial protrusion of the disk.In patients with suspicion of hernial protrusion of the MPD, when the implementation of MRI is impossible, or the results obtained are uninformative, computed -tomographic (CT) myelography acquires a special diagnostic value.

Private diagnostic specialists who interpret the results of the studies, as a rule, exaggerate the degree of damage to the disk due to the impossibility of comparing clinical data with “finds” during tomography.Conclusions such as “changes correspond to the age of the patient” are almost never found in research protocols.Despite the improvement of neuroimaging techniques, the responsibility for the correctly deceived diagnosis lies on the shoulders of the clinician, since only he can compare the clinical picture with the data obtained during tomography.An increase in the resolution of tomographs slightly improved surgical treatment outcomes, but deviations from the norm in asymptomatic patients began to be detected. The process of processes accompanying the degenerative -distortical lesion of the spine has undergone serious progress in recent years.The arthropathy of the arched joints is widespread in the general population and is detected quite often in people of the middle and older age group during CT research.Degenerative changes in MPD, which are also widely used, are quite often detected, and MRI is a more specific method for their diagnosis.At the same time, pronounced changes in the MPD are not uncommon, not accompanied by a rupture of the fibrous ring, but only manifested by a slight “stab” of the disk into the lumen of the spinal canal or intervertebral holes.In some cases, degenerative processes occurring in the MPD can lead to the destruction of the fibrous ring with subsequent ruptures, which causes the migration of part of the pulpic nucleus outside the disk with compression of the adjacent roots of the spinal cord.The assertion that if pain in the leg is noted, then there must necessarily be infringed on the spinal cord roots is not entirely true.To the pain in the buttock with irradiation on the posterior surface of the thigh can lead both the degeneration of the MPD itself and the arched intervertebral joints.For a true attack of ishialgia caused by compression of the Koreshka of the nerve of the MPD hernia, pain radiates on the posterior surface of the thigh and lower leg.An indefinite pain, limited only to the gluteal area or thigh area without distribution along the sciatic nerve, as well as bilateral pain in the gluteal areas or hips that change their localization (either on the right, then on the left), are more often caused by arthropathy of arched joints or diffuse degeneration of the MPD.The clinical picture of the compression of the Koruska of the MPD hernia may also be a concomitant pathology (for example, arthrosis of the knee joints).In patients with such pains, surgical treatment will not have the proper effect regardless of which pathology will be detected by tomographic examination.In other words, in patients only with the clinic of pain in the back, removal of the MPD hernia will be ineffective, even if tomograms are determined by the protrusion of the MPD, as usual and happens.But there are also patients in whom the typical picture of Ishias is accompanied by a pronounced disabled pain syndrome, while during studies performed using highly perceptive tomographs, the compression of the roots of the spinal cord is not determined.This category of patients is inappropriate to perform surgical intervention, since over time, radicular symptoms, as a rule, subside.

It is necessary to clearly imagine the mechanisms leading to the development of hernial protrusion of the MPD in order to recommend to patients the volume of permissible movements, not forgetting about work activity.The forces that contribute to the formation of hernial protrusion are the result of degenerative changes in the MPD and a decrease in vertical (height) of both the fibrous ring and the pulpoose nucleus.The stabbing fragment of the MPD in 80% shifts in the posterior -beard direction, while introducing into the lumen of the spinal canal and the medial sections of the intervertebral hole.This displacement of the hernia of the MPD towards the midline is facilitated by the holding force of the posterior longitudinal ligament.Up to 10% of hernial protrusions are localized laterally and spread to the intervertebral hole (forsin hernias) or at the outer edge of the hole where the cerebrospinal spine comes out of it, thereby squeezing it.

In the process of vital activity, dehydration and degenerative changes lead to loss of the height of the MPD.These pathological processes involve both a fibrous ring and a pulpic nucleus.The more pronounced destruction of the pulpoose nucleus against the backdrop of the concomitant degeneration of the fibrous ring, as a rule, leads only to the loss of the height of the MPD without its significant gatherings.With predominant changes in the fibrous ring, the vertical forces affecting the preserved pulpic nucleus and which are a derivative of their own weight, as well as the muscles of the back, acting on the disk in the lateral direction, exert excess pressure on the remaining fragment of the pulpoose nucleus, which is not able to retain the fibrous ring in place.

The summation of these two forces leads to an increase in centrifugal pressure on the MPD, which, together with the stretching component acting on the fiber of the fibrous ring, can lead to its rupture and fragment of fragments of the remaining pulp nucleus.After a hernial protrusion was formed, and the “redundant” fragment of the pulpic nucleus was outside the fibrous ring, the structure of the MPD again becomes stable [2].As a result of the forces affecting the degeneratively altered core and fibrous ring of the MPD, they are balanced, and their vector, which contributes to further protrusion of fragments of the nucleus, fades away.In some cases, partial degenerative changes in the pulpos nucleus contribute to gas formation inside the MPD, followed by excessive pressure on its remaining fragment.The formation of a hernia is also accompanied by the process of gas formation inside the disk.

Excessive and sharp physical activity shown on the patient’s back, against the background of the existing degenerative -dystrophic lesion of the spine, is usually only a trigger that leads to a detailed clinical picture of a compression radicular syndrome, which is often and erroneously regarded by the patients themselves, like the primordial of lumbar -icialgia.Clinically, MPD hernia can manifest itself with reflex and compression syndromes.Syndromes are referred to compression, in which above hernial protrusion is pulled, squeezed and deformed, blood vessels or spinal cord is compressed and deformed.Reflex reflexes include syndromes caused by the effects of the disk hernia on the receptors of these structures, mainly the end of the return spinal nerves, which leads to the development of reflex and tonic disorders manifested by vasomotor, dystrophic, myofascial disorders.

As noted above, surgical treatment with degenerative -dystrophic lesion of the posvinor is advisable only in 10% of patients, the remaining 90% react well to conservative measures.The basic principles of using the latter are:

1. relief of pain syndrome;
2. restoration of the correct posture to maintain the fixation ability of the changed MPD;
3. elimination of muscle and tonic disorders;
4. restoration of blood circulation in roots and spinal cord;
5. normalization of conductivity in nervous fiber;
6. elimination of cicatricial and spacing changes;
7. Relocation of psycho -somatic disorders.

Treatment

Today, in the treatment of osteochondrosis and its complications, drugs of the following groups are used:

1. Net -ore anti -inflammatory drugs (NSAIDs) - in the form of tablets or injections of drugs.These funds have the ability to reduce pain, reduce the activity of inflammation.However, the effect of their use does not last long - from several hours to two to three days.Therefore, such funds must be taken for a long time - weeks, and sometimes months.At the same time, these drugs negatively affect the mucous membranes of the gastrointestinal tract.Their long -term reception is fraught with the development of gastritis, ulcerative lesions.In addition, they can negatively affect the work of kidneys, liver, and contribute to the development of hypertension.And, at the same time, these funds do not contribute to the cleansing of discs from dead cells.Therefore, their use is only a way to relieve symptoms for a while, but not to eliminate the main problem.
2. CTEPOID (gopmonal) anti -inflammatory drugs.As a rule, they are used for severe and impenetrable pains accompanying hernia, radiculitis, Ishias, etc. Gopmons have the ability to eliminate manifestations of inflammation (due to oppression of the immune system), relieve pain.But they also negatively affect the mucous membranes of the stomach and intestines, promote leaching of calcium from bones, inhibit the production of their own GOPMONs.And do not contribute to cleansing the focus of dead cells.
3. Papasmolics are drugs that affect the muscles or nerves that go to the muscles and cause relaxation of skeletal muscles.These means help to relieve muscle clamps for a while, reduce pain and improve blood flow.But at the same time, they do not help cleanse tissue from dead cells.Therefore, they do not contribute to cure for osteochondrosis.
4. Epiduppal blockade - the introduction of painkillers and gopmonal agents into the space between the solid brain shell and the periosteum covering the vertebrae.It is used, as a rule, for intense pains - in the acute period of the intervertebral hernia, with severe radiculitis, Ishias.Depending on the composition, such an injection helps relieve pain for a period of several hours to several days.After the expiration date, the manifestations of the disease are returned, becauseThe procedure does not help restore metabolic processes in discs.In addition, when it is carried out, there is a risk of injury to blood vessels and nerves.

Conservative treatment methods include various orthopedic effects on the spine (corset immobilization, traction, manual therapy), physiotherapy (therapeutic massage, physiotherapy exercises, acupuncture, electrotherapy, mudding, various kinds of heating), paravertebral, peridural blockade and medication therapy.The treatment of degenerative -dystrophic lesion of the spine should be complex and phased.As a rule, the general principle of conservative measures is the appointment of analgesics, non -steroidal anti -inflammatory drugs (NSAIDs), muscle relaxants and physiotherapy.

The analgesic effect is achieved by the appointment of diclofenac, ketoprofen, lornoxicam, tramadol.A pronounced analgesic and anti -inflammatory effect has Loroxes, existing in both injection and tablet forms.

NSAIDs are the most widely used drugs for degenerative -dystrophic damage to the spine.They have an anti -inflammatory, analgesic and antipyretic effect associated with the suppression of the enzyme cyclooxygenase (COC -1 and TsOS -2), which regulates the transformation of arachidonic acid into prostaglandins, prostacillas, thromboxans.In the elderly and patients with risk factors for side effects, it is advisable to carry out the "cover" of the gastrotrotectors under the "cover".In such patients, upon completion of the course of injection therapy of NSAIDs, the transition to the tablet forms of the COO -2 inhibitors, which have a lower severity of side effects from the gastrointestinal tract, is advisable.

To eliminate pain associated with increasing muscle tone, it is advisable to include central musclexants in complex therapy.

Surgical treatment of degenerative -dystrophic lesion of the spine is justified with the ineffectiveness of complex conservative measures (within 2-3 weeks) in patients with hernias of MPD (usually more than 10 mm) and non -enchanting radicular symptoms.There are emergency indications for surgical intervention with a “dropped” sequestra in the lumen of the spinal canal and expressed compression of the roots of the spinal cord.The development of caudal syndrome is facilitated by acute radiculomilohemia, leading to severe hyperalgic syndrome, when even the prescription of drug analgesics, the use of blockade (with glucocorticoid and anesthetic) does not reduce the severity of pain.It is important to note that the absolute size of the disk hernia does not have a determining value for making the final decision on surgical intervention and should be considered in connection with the clinical picture and finds detected by tomographical examination. In 95% of cases, open access to the vertebral canal is used in the hernia.Various discopation techniques (cold -plasma coagulation, laser reconstruction, etc.) did not at present at present, and their use is justified only for protrusions of the MPD.The classic open microsurgical removal of the hernia of the disk is carried out using microsurgical tools, binocular magnifiers or an operational microscope.Analysis of distant treatment results (within more than 2 years) 13,359 patients who underwent the removal of the MPD hernia, 6135 of which the sequestral was removed, and 7224 aggressive discsctomy was carried out, showed that the relapse of pain was found 2.5 times more often (27.8% versus 11.6%) in patients who have moved aggressiveThe discoctomy, while relapse of hernias was noted 2 times more likely (7% versus 3.5%) in patients who were only removing sequestration.The quality of life is reduced more in patients experiencing pain syndrome, while repeated hernia formation is not always manifested clinically.

In conclusion, I would once again emphasize the need for a thorough clinical examination and analysis of tomograms to make an optimal decision on the choice of tactics for the treatment of a particular patient.